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29822 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - CITY OF CUPEi RTINO , '' - BUILDING-ELECTRICAL PERMIT NO. //�Q /�/�/� BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L N X C L BUILDING PROJECT IDENTIF'ICA'TION - V BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE C� Zr � �.LgYO OWNER'S NAME: PHONE: CO RACTOR'S NAME: 5 .i 0' • NIC CONTROL# R HITEC /ENGIN ER: - IC NO: ADDRESS: - - ❑ 803 / CONTACT: PHONE: - BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby if,.but I am Beamed under provisions of Chapter 9(commencing SOB DESCRIPTION ❑00 with Section 7001 Division3ofthe Bmsinessand Professions Cmb.mdm license PERMIT ISSUANCE RESIDENTIAL: F full forme and effect yyyq��Uz License Class�Lk.% ❑SFDWL El KITCHEN REMODEL 6 Date 'Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE F ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL Fpp..[=2 Z I understand my plans shall be used as public records MODIFICATION Z :41 t UPT02MAMPS ,'; ❑ I El INTERIOR ❑CHIMNEY REPAIR �isnE. Licensed Professional .. 201-IOMAMPS IMPROVEMENT' yp5 OWNER-BUILDER DECLARATION OVER 1000 AMPS - C1 BATH REMODEIIREPAIR DEMOLITION -' PI ii hereby affirm that 11. exempt from the Contractor's License Law for the (]OTHER ?0qx5y 6 U fallowing reason.(Section]OJLS,Business and Professions Cale:Any city or county SIGNS ELECTRICAL W 3 F which in issuance,also t re e construct.the an)q improve,demolish, file repair any structure F-'�❑ bpriar islcense purbarequiree the for such Courennitmicense Law PCmpter9 SPECIAL CIRCUIT/A1ISC. y thmhe is licensed pursuant 70th)of Division 3 the Connacmr's License Law(Chode)or CC that he enmpt,tSecrion]Und b basis for of the eged exempt Professions Code)or TEMP METER OR POLE INST. COMMERCIAL: d e y Nm he is exempt Uerefmm and be basis for We alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION iWWi(q k• Section 7031 5 by y applicant for a pei t subjects Ne applicant to a civet penally of - POWER DEVICES sz1'm"m r ❑TENANT ❑FOOD SERVICE not room ban five hundred dollars($SW) F Q El 1, f the property.or my employ with g s their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT will do thw k ad me structure snot intended B df sale(Sea.VO4,U Business El OTHER and P f Cod:The`Contraciors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who bmlds or improves thereon,and who does such work himself or through his owri employees,provided that such improvements are nor intended or Offered for NEW RESIDENTIAL ELECTS SQ FT. sale.If.however,be building or impmvement is sold within one year ofcompletion;the SQ.FT..FLOOR AREA '$/SQ.ET. owner-builder will have the burden of proving that he did not build or improve for pur- p I' D�p•T�s,, pose of sale.). , 4� ;`Y l D O I,as owner of the property,am exclusively contracting with licensed contractors to 'construct the project(Sec.7044,Business and Professions Code:)The Convacmr's cerise Law does not apply to on owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE MAY 'O �JOnf'I� who contracts for such projects with a conaaem ctobidlicsW 2 pursuant to the Contractor's Liceasolaw. PERMIT ISSUANCE ❑I am exempt under Sec. ,B&P C for thisreasan Ur el"I.— no Date ALTER-DRAIN&VENT-WATER(FA) n ✓VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2 !� A•/\0 1 hereby aifmn under penalty ofpcip,One of the following declamtkmxs V V V ❑I have and will maintain a CertlficateofConsent to self-insure,,Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION action,as provided for by Section 37W of be Labor Code,for the Performance of the work for which thin permit is issued. I L FIXTURES-PER TRAP. ❑ I have and will maintain Worker's Compensation Insurance,as required by Section 37W of the tabor Code,for be performance of the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP,r APN My Worker's Compensation Insurance carrier and Policy number am: Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE "' GREASRINDUSTRL WASTE INTERCEPTOR (This section read out be completed ifthe permit is future hundred dollars($100) BUILDING DIVISION MES or less.) GREASE TRAP PLANCHECK FEE 02 I certify that in the performance ofthe work for which this Permit is issuad,Iball - Qz y Person in any manner so` F rep jpp, eWr� SEWEk-SANITARY-STORM EA. FT. - - nal employ�an io b coom b t m th kers'Compen- ENERGY FEE' ' sa[ion Lews of CaI fumrg Die WATER HEATER WNENT/ELECTR z 2. Applicant' -31-� GRADING FEE h NOTICETOAPo this enificamof En tion,you should WATER SYSTEMNREATING E-' become subjmt the Work rs Compensation provisions of the Labor Codq you must 50165 FEE _ forthwith comply with such provisions or this permit shall be deemed revoked. - WATER SERVICE' O CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.FT PAID Lw15Ll ec Thereby effrm that there is aconswction lending agency For the performance of - Date Rted F-' the work for which this permit is issued(Sec.3097,Civ.C.) 0Lender's Name TOTAL: z• 4UU Lender's Address TOTAL: y I mnify but 1 have read Nisapplicannin and state that the above information is BUILDING FEE y correct l agree to comply with all city and county ordirane)s and state laws relating to QTY. MECHANICAL PERMIT FEE L) Z' building construction,and hereby authorize representatives ofthis city to enter upon the SEISMICFEE above-mentioned property for inspection purposes. i PERMITISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECH. , - m consequent the granting of this permit PLUMBING - APPLICA U DEE TANG ANDWILLCOMPL [TH ALL NON-POINT AIR HANDLING UNIT IO,WO CFM) - - $OURC EG ATIONS.. MECHANI Z- AIR HANDLING UNIT(OVER IU.WO CFM) CONSTRUCTION TA Si atumof Appli as or Date. EXHAUST HOOD(W/DUC1) AZAR S AT REALS DISCLOSURE HOUSING MITIGATI FEE Will eapplicantor wilding occupant store or handle hazardous material HEATING UNIT(TO IW,O(a)BTU) s defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety e,Seen.255320)? HEATING UNIT(OVER 100.000 BTU) - Dyes ❑No r PAID VENTILATION PAN(SINGLE RESID) - Will Ne applicant or future building occupant use equipment or devices which - Dam Receipt k 01 emit hazardous air contaminants as defined by the Bay Area Air Quality Management .BOILER-COME(SHE OR 100,000 BTU) Ldmanut " " TOTAL: s F1 No BOILER-COMP(OVER100.000 BTU) mad be hazardous materials requiremems under Chapter 6 95 of the Cali- Alk CONDITIONER ISSUANCE DATE &Safety Code,Sections 25505.25533 and 25534.I understand but if be NEW RESIDENTIAL MECH. SQ.FT. not currently have stennt,Dui it is my responsibility to notify the occupant ments which must be met prior to issuance of a Certificate of Occupancythorized agent Uate TOTAL: ISSUED BY: OFFICE i..